The Irreparable Rotator Cuff Tear
Knowledge that empowers
What is it?
An irreparable rotator cuff tear typically refers to a large or massive sized rotator cuff tear that:
- Cannot be repaired with conventional surgical repair techniques; or
- Could be repaired with a conventional surgical repair technique, however, it is highly likely to fail or would not lead to an improvement in the function of the shoulder.
Whilst we often think of the tendon when talking about rotator cuff injury, it is extremely important to consider both the tendon and the muscle belly. A functional rotator cuff relies on having a functioning muscle (i.e. one that can generate force by contracting) and a strong, structurally intact tendon portion.
Following a large or massive tear of the rotator cuff, a number of changes can occur in the rotator cuff muscle belly and its tendon. Because the tendon is no longer attached to the humerus (upper arm bone), over time the tendon can migrate back towards the scapula (shoulder blade) in a process described as tendon retraction. If this tendon retraction progresses and is left untreated without surgery, it can become extremely difficult or even impossible to reattach it to the humerus at a later stage.
Another reason that a rotator cuff tear may be deemed irreparable is that the muscle belly of the rotator cuff can deteriorate. Over time the muscle loses its size (atrophies) and fatty tissue may develop in the muscle belly (fatty infiltration). These factors are very important to consider before attempting repair of a rotator cuff with surgery. In cases such as this, even if the tendon is repaired back to the bone, the atrophied and fat infiltrated muscle cannot generate force and therefore the rotator cuff tendon cannot function as it normally would.
Who is affected?
The changes in the rotator cuff described above can occur after large and massive tears of the rotator cuff
It can be difficult to predict how quickly these changes may progress. Should someone sustain a large or massive tear of the rotator cuff after a traumatic incident like a fall, it is often critical to repair the tendon with surgery within 4-6 weeks. Early repair significantly reduces the chance of the tear becoming unrepairable.
Because time is a critical factor, irreparable rotator cuff tears are seen in patients where there has been a significant delay in diagnosis and/or referral to a shoulder specialist after injury.
Irreparable rotator cuff tears can also develop after a conventional surgical repair of a large or massive rotator cuff tear failure. This can occur because the repaired tendon simply did not heal to the bone, the structure of the suture repair failed, there was poor compliance with rehabilitation after surgery or another traumatic injury to the repaired tendon was sustained after surgery.
What are the symptoms?
Those with an irreparable rotator cuff tear may experience significant weakness in certain movements of the shoulder, and this is typically dependent on exactly which part/s of the rotator cuff tendon was torn.
Pain may also be present in these movements or at rest. It may be uncomfortable to sleep on the shoulder or bear weight through the arm.
How is the diagnosis made?
An MRI scan of the shoulder is used to determine whether a tear of the rotator cuff is repairable or irreparable. Both the rotator cuff tendon and the relevant muscle belly are evaluated to determine the amount of tendon retraction, muscle atrophy and fatty infiltration.
What is the prognosis?
Unfortunately, if a rotator cuff tear is deemed irreparable, the function of the shoulder is normally significantly impaired and does not improve greatly with strengthening of the shoulder.
Because a major role of the rotator cuff is to keep the head of the humerus bone centred in its socket (glenoid), a large or massive rotator cuff tear causes the humeral head to move excessively. Over time this leads to increased shearing and compressive forces through the joint which can lead to development of arthritis in the joint – known as rotator cuff tear arthropathy.
Irreparable rotator cuff tears pose a great problem to shoulder specialists, physiotherapists and their patients, as conventional surgical repair and rehabilitation are ineffective.
With arthritic change being a case of “when” and not “if”, those with an irreparable rotator cuff tendon tear may spend a significant period of their life waiting for arthritis to develop to such a point that they then require a reverse total shoulder replacement.
Reverse total shoulder replacement can be greatly beneficial for some, particularly those suffering from the pain of arthritis, however younger patients with a greater desire to participate in higher level activity can be left unsatisfied with the restricted range of motion and weakness experienced after reverse total shoulder replacement.
Thanks to recent advances in modern surgical techniques and training, Associate Professor Raniga is able to offer highly specialised, alternative surgical procedures to a select group of patients with irreparable rotator cuff tears. These techniques and some of their indications are described below in the surgical treatment section of this page.
Non surgical treatment
As described previously, non-surgical management of an irreparable rotator cuff tear is normally not effective in restoring strength and normal function of the shoulder.
However, non-surgical management may include:
- a strengthening program for the muscles of the shoulder not affected by the rotator cuff tear
- non-steroidal anti-inflammatory medication for pain relief – NB: we recommend discussing this with your shoulder specialist, general practitioner or pharmacist prior to commencing anti-inflammatory medication
- advice on suitable work and/or recreational activities that will benefit your general health
- range of motion exercises to maintain normal motion of the shoulder joint
Surgical treatment
Planning for surgical management of the irreparable rotator cuff requires careful consideration of a number of factors including the exact size and location of injury, age of the patient, their general health and the expected outcomes of surgery.
Generally speaking, the primary aim of surgery for the irreparable rotator cuff is to decrease levels of pain and improve the physical function of the shoulder i.e. ability to move the shoulder in daily activities. Should recovery be uncomplicated, most patients will see significant improvement in pain and range of motion. Despite this, it is important to understand that these procedures do not entirely restore ‘normal’ function or strength to the shoulder.
The surgical management is either with surgical techniques considered to be ‘joint-preserving’ (for younger patients with no arthritis) or with a reverse total shoulder arthroplasty/replacement (for older patients with arthritis).
In this section we focus on the novel ‘joint-preserving’ procedures. These advanced surgical techniques allow us to preserve the patients shoulder joint and improve its biomechanics, alleviate pain and provide mechanical drivers to restore motion. In turn, this can reduce pain in the shoulder both with movement and whilst at rest. These procedures may reduce or even prevent the progression of any arthritic change that occur in the shoulder joint with an irreparable rotator cuff injury.
Recovery from these surgeries typically involves a six-week period of immobilisation in a special shoulder brace designed to reduce tension on the chosen repair. After six weeks, a graded rehabilitation program commences to restore the ability to externally rotate and elevate the arm. Strengthening exercises typically commence at 12 weeks after surgery. Total recovery may take upwards of six to twelve months to restore satisfactory strength and range of motion for the shoulder.
Lower Trapezius Tendon Transfer
This surgical technique is performed for patients who have a large or massive irreparable tear of the ‘postero-superior’ portion of the rotator cuff – that is, the tendon portion of the supraspinatus and infraspinatus muscles.
Patients with this type of tear typically experience significant weakness in movements that involve external rotation (turning the arm outwards from the body), elevation (lifting upwards) or a combination of the two movements in activities such as drinking a glass of water, waving, the cocking phase of throwing a ball or reaching for a high shelf. In order for this procedure to be successful, the subscapularis portion of the rotator cuff must be intact.
Research has shown that the lower trapezius muscle has almost the perfect line of pull to replace the irreparable rotator cuff muscles. This surgery involves detaching part of the lower trapezius tendon from its attachment on the scapula (shoulder blade) and then attaching it to the rotator cuff footprint on the humerus (upper arm bone) with a donated achilles tendon graft.
This advanced surgical technique allows us to preserve the patients shoulder joint and improve its biomechanics, alleviate pain and provide mechanical drivers to restore motion. In turn, this can reduce pain in the shoulder both with movement and whilst at rest. These procedures may reduce or even prevent the progression of any arthritic change that occur in the shoulder joint with an irreparable rotator cuff injury.
Superior Capsular Reconstruction
This procedure may be offered to those patients with an irrepairable supraspinatus tendon – the uppermost portion of the rotator cuff.
Patients with this injury often report significant weakness with associated pain in tasks that involve elevating the arm. External and internal rotation strength are not typically affected by this injury.
The surgery itself involves reconstructing the upper most aspect of the joint capsule where the supraspinatus portion of the tendon would normally lie. A special tissue graft (from human skin) is placed into the shoulder and attached in tension with sutures and bone anchors to the top of the glenoid and humerus bones.
This graft has structural properties to keep the humeral head centred in the socket with shoulder movements, restoring biomechanics.
This advanced surgical technique allows us to preserve the patients shoulder joint and improve its biomechanics, alleviate pain and provide mechanical drivers to restore motion. In turn, this can reduce pain in the shoulder both with movement and whilst at rest. These procedures may reduce or even prevent the progression of any arthritic change that occur in the shoulder joint with an irreparable rotator cuff injury.
Reverse Shoulder Arthroplasty/Replacement
This procedure is offered to older low-demand patients with an irreparable rotator cuff who are not suitable for the joint preservation surgery or any patient with an irreparable rotator cuff who has arthritis.
A Reverse Shoulder Replacement is a special type of shoulder replacement prosthesis that changes the biomechanics of the shoulder. It is a type shoulder replacement that does not rely on the rotator cuff – it relies on the large deltoid muscle to work. Hence, it has revolutionised the treatment of patients with a torn rotator cuff tendons and arthritis.